Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from potentially unnecessary psychotropic medications. Specifically, two residents were affected by this deficiency. One resident, admitted to the facility with diagnoses including high blood pressure, Bipolar Disorder, and dementia, was prescribed Trazodone and Ziprasidone. However, the facility did not maintain documentation of the consultant pharmacist's reports, which noted irregularities and recommendations regarding these medications. Another resident, admitted with Alzheimer's Disease, dementia, and malnutrition, was prescribed several psychotropic medications, including Escitalopram, Divalproex, Mirtazapine, and Trazodone. The physician orders for these medications did not specify the conditions they were intended to treat, as required. Additionally, the facility failed to provide documentation of the consultant pharmacist's report, which also noted irregularities and recommendations. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to identify specific conditions for treatment with psychotropic medications and to maintain necessary documentation. This lack of documentation and failure to ensure medication regimens were free from unnecessary medications contributed to the deficiency.
Plan Of Correction
Residents #4 and #78 had no negative outcome. Diagnosis was clarified by physician and entered into medical record for treatment. To identify other residents that have the potential to be affected, the DON/designee reviewed current residents on psychotropic medications to ensure resident medication regimens are free from unnecessary medications and that there is a diagnosed specific condition for treatment. Corrections will be made as needed. To prevent this from recurring, the RDCS/designee educated licensed nursing on the regulatory requirements of F758 on ensuring resident medication regimens are free from unnecessary medications, that the consult pharmacist report is in the medical record (and addressed) and that there is a diagnosed specific condition for treatment. To monitor and maintain ongoing compliance the DON/designee will review the medical record of 3 residents on psychotropic medications weekly x4 then monthly x2 to ensure resident medication regimens are free from unnecessary medications, that the consult pharmacist report is in the medical record (and addressed) and that there is a diagnosed specific condition for treatment. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.